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The JAMA Forum
July 3, 2018

Housing as a Step to Better Health

Author Affiliations
  • 1Senior fellow, Economic Studies, at the Brookings Institution in Washington, DC
JAMA. 2018;320(1):21-22. doi:10.1001/jama.2018.7736

The medical profession now broadly recognizes that there is much more to good health than having affordable access to excellent medical care. In particular, housing difficulties are seen as comprising an important determinant in the underlying health condition of many families, and they often are a factor in acute episodes of illness. Poor living conditions can trigger such developments as respiratory problems and stress-related illness, and many falls and hospitalizations among elderly individuals result directly from unsafe housing.


Action and Obstacles

As Howard Koh, MD, MPH, and Robert Restuccia, MPA, wrote last year in a JAMA Forum, the health care community is increasingly partnering with local organizations and housing advocates to address housing issues, including homelessness, that contribute to ill-health. The National League of Cities, the National Governors Association, and other bodies are identifying best practices for state and local lawmakers and officials seeking to use housing to help improve health outcomes and save money. Meanwhile, the body of research on health and housing is growing; the University of California, San Francisco, maintains an online library tracking the expanding research literature on the connection between health and investments in social sectors, such as housing.

Despite this attention, there are obstacles to making full use of housing as a social determinant of health. Because of such factors as privacy concerns and simple bureaucratic inertia, for instance, the sharing of data needed for successful partnerships often does not occur. An even bigger problem is that many potential partnerships encounter the “wrong pocket” problem, in which the bankable savings associated with a health-related investment in the housing budget show up in another sector—the health budget—rather than in the housing sector’s bottom line. This makes it hard to gain support from housing agencies for investments to promote health.

Promoting Housing-Health Partnerships

So how can we encourage investment in housing to improve health and avoid some medical costs?

In a recent Brookings report I coauthored, we explored ways to do this. In addition to tackling some of the general issues that impede cross-sector partnerships, such as the problem of sharing data, we identified a number of specific steps that would foster housing-health partnerships. In particular, we identified several possible solutions to the wrong pocket problem and other budget and payment disincentives. Among them:

  • Make Creative Use of the Community Health Needs Assessment (CHNA) Requirement

Sometimes a financial stick can help cross-sector investments. For instance, the US Treasury requires nonprofit hospitals to invest in “community benefit” as a condition of their tax exemption. Partly in response to this requirement, as well as to pursue their philanthropic goals, several health systems have invested significantly in housing, such as Bon Secours in Baltimore. The treasury requirement thus serves as a partial antidote to the wrong-pocket problem by encouraging hospitals to invest in the community. The treasury could spur further investment in housing by clarifying its CHNA rules and encouraging creativity, because today many hospitals are unsure if they will receive CHNA credit for innovative housing investments.

  • Expand the Use of Home-Based Health Services

Sometimes simple payment and budget flexibility helps. For instance, the federal government could use housing more extensively as a partner for improving health by making greater use of Medicaid’s Managed Care 1915(b) and 1915(c) Home and Community Based Service waivers. These waivers from federal rules allow communities to use paid social workers more broadly to provide home-based care and so avoid expensive nursing home care. In addition, state and local governments could make it easier for elderly and infirm individuals to age more safely and less expensively in their own homes by helping communities launch such approaches as senior villages. These groups are nonprofit membership organizations that use volunteers, and sometimes paid staff, to provide a range of home-based support services. Recognizing how these arrangements can improve health and reduce health costs, some jurisdictions now invest in creating villages to reap savings in health and service budgets. For instance, the Washington, DC, Office on Aging offers competitive grants to help establish villages in poorer areas of the city and to train staff and volunteers.

  • Amend the Federal Law to Permit Use of Medicaid Funds for Room and Board and Direct Housing Capital Costs

The federal government has used the waiver authority available under Section 1115 of the Social Security Act to permit states to use Medicaid funds to pursue the program’s objectives in innovative ways. Although the law does permit Medicaid funds to be used for some housing pilots, Medicaid cannot cover room and board and capital costs. This limits significantly the opportunity to use strategic housing strategies under Medicaid to achieve savings and improve health, even when a housing agency wishes to cooperate. To address these constraints, Congress should ease the limitations on using Medicaid for housing in cases where there is sufficient research to suggest the result could be better health at less cost.

  • Grant Medicare Broader Authority to Conduct Pilots and Grant Waivers, Allowing the Program to Experiment With More Housing Partnerships

Medicare has less statutory authority than Medicaid to experiment with housing partnerships to improve health at less cost. Congress did take a step forward this February in giving more flexibility when it enacted the CHRONIC Act. That will give private, managed care Medicare Advantage plans greater authority to use funds for nonmedical services, such as housing services, where it could improve health outcomes. Congress could build on this helpful step in a number of ways. For instance, as the Bipartisan Policy Center has recommended, by making it easier for Medicare managed care organizations to pay for home alterations, Congress could also give Medicare greater statutory waiver authority to work with states to experiment with a range of housing-based health strategies. Because Medicare is not a joint federal-state program like Medicaid, such a waiver authority would likely need a budget arrangement to encourage states to be innovative by rewarding them. One way to do that would be through a “shared savings” approach, in which a state could negotiate with the federal government for a portion of the potential savings to Medicare to cover the state’s housing investment.

Housing is assuming its appropriately prominent place among social determinants of health. Taking steps now to foster housing-based strategies and analyze their effects should provide a fuller understanding of housing’s relationship to health, thus helping ensure that housing plays its full potential role.

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Article Information

Corresponding Author: Stuart M. Butler, PhD (smbutler@brookings.edu).

Published Online: May 16, 2018, at https://newsatjama.jama.com/category/the-jama-forum/.

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